Will discuss with patient appropriate pain medicine, rx for 3 days as per State and FDA requirements

  Episodic/Focused SOAP Note for 46-Year-Old Female with Right Ankle Pain The foot and ankle are complex, consisting of 26 bones, 33 joints, and more than 100 muscles, tendons and ligaments (Arthritis Foundation, n.d.). The lower extremity is capable of multiple planes of movement such as dorsiflexion, plantar flexion, pivot and rotate, pronation and supination (Ball, et. al., 2019). Because of this complexity of movement, ankle injury and sprain is quite common (Chung & Chung, 2019). The case presented is a 46-year old female who was playing soccer and heard a pop in her right ankle. Attached is the episodic SOAP note from her visit to the clinic to see the APRN that is her primary care provider. Patient Information: MC, 46, Female, Caucasian S. CC Right ankle pain s/p hearing “pop” while playing soccer on Saturday, April 11, 2020 HPI: 46 y/o white female, alert and oriented x4, c/o pain in both ankles, more in right than left. Reports was playing soccer Saturday (4 days ago), stopped abruptly, heard “pop” in right ankle. Able to bear weight but it is painful (8/10) today upon this appointment. Location: Right Ankle Onset: 4 days ago Character: Throbbing, aching pain in right ankle at rest. Sharp and stabbing upon standing. Associated signs and symptoms: wave of nausea on Saturday when injury occurred Timing: rt ankle pain increases upon standing and walking, constant ache and throbbing at rest. Exacerbating/ relieving factors: standing and walking exacerbates pain. Ibuprofen has brought pain down slightly. Last dose of Ibuprofen, 600mg was 6 hours ago. Severity: 6/10 pain scale at rest without medication; 8/10 upon ambulation without medication Current Medications: Multivitamin daily, Edarbi 40mg once daily, cetirizine 10mg once daily prn allergic rhinitis, Ibuprofen, 600mg PO 6 hours ago. Allergies: No known drug allergies, no food allergies, reports seasonal allergies controlled by OTC cetirizine/daily, no latex allergy PMHx: HTN, Seasonal allergies. Immunizations UTD to include flu shot October 2019, Tdap August 2018, Hep B series in 1992. G2p2 vaginal deliveries. Hospitalized in 1999 with Rotavirus during first pregnancy. Surgeries: Fx left rad/ulna closed reduction 2001, ORIF left rad/ulna with bone graft from left hip after malunion of fx. Ventral Hernia repair 2008. BTL 2009. Soc Hx: Pt is a teacher, married for 23 years, two children, 16 and 20. 20 yr old male is away at college. 16-year-old female lives at home with family. Hobbies include playing soccer, reading, boating. Utilizes seat belts 100% of time. Nonsmoker/tobacco of any kind. Reports drinks occasional (once/mo) glass of wine, two max. Reports when she was young, she would drink only once or twice per year but many drinks on those occasions. Owns home, has own transportation to make it to appointments. Smoke detectors in home. Admits to occasionally texting while driving but instilled in children to NOT. Husband is at appointment with her in case need driver to get home. Fam Hx: Mother has HTN, COPD, Type 2 Diabetes (all controlled with meds), hx of episodic depression. Father had HTN, high cholesterol, alcoholism, prescription drug use/abuse, had two head injuries with subdural hematomas, one while active duty in Navy in his 20s (1971?), the other after auto accident while driving intoxicated in 1985. Father died at age of 46 in 1991 from suspected brain aneurysm. Maternal grandmother died at 90 from age related conditions. She had HTN, GERD significant enough to have her stomach above her diaphragm. Maternal grandfather died in his 70s from lung cancer secondary to prostate cancer. He had hx of smoking, AAA repair, prostate cancer, lung cancer, HTN. Paternal grandmother died from pancreatic cancer in 1975 (in her 50s?), paternal grandfather was smoker, died in his 70s, unsure why as was not close to him. Brother and sister are from maternal first marriage, both smokers but no real health issues known. Children are healthy, no chronic illness ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. Example of Complete ROS: GENERAL: 46 yr-old overweight white female in slight distress from pain right ankle. Denies weight loss or gain, fever, chills, weakness or fatigue. HEAD: No bumps or bruising. Denies falling or hitting head while playing soccer. HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: denies GU issues, no burning or difficulty urinating. No flank pain. Reports post-menopausal and cannot remember LMP “well over a year ago”. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: Pain right ankle, tenderness and swollen. Pain left ankle but not as much as right. Denies back pain and upper extremity pain or stiffness. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of cold or heat intolerance. No polyuria or polydipsia. Reports hot natured and more so at night “from hormones” ALLERGIES: No history of asthma, hives, eczema. Occasional seasonal rhinitis, controlled today with OTC cetirizine. O. Physical exam: General: 46 y/o white female in pain rt ankle, awake and alert x4. BP 125/75 (Pain 8/10 after ambulating into room) P 86, R 18, pox98% on ra, weight 171, BMI 30, Head: normocephalic, no trauma noted to head. Skin: intact, no wounds or rashes noted to exposed skin. Swelling noted to right ankle area, no redness or lesions noted. HEENT: Pupils are equal, round, reactive to light. Ears intact, tympanic membranes not assessed, Denies loss of hearing, denies ear pain or drainage. Nose intact, denies difficulty breathing, no deviation upon inspection. Throat intact, no difficulty swallowing, mucose noted to be pink and moist. Neck: No goiter noted. No thyromegaly noted. Chest: Chest symmetrical upon inspection, BBS CTA, no respiratory distress noted, no use of accessory muscles noted. Cardiovascular: S1-S2, no rubs, Gallup or murmurs noted. Abdomen: contoured and round. BS+ x 4 quadrants, no masses noted upon palpation. GU/GYN: denies urinary hesitancy, burning, frequency of urination. Extremities: No deformities noted upper extremities, full ROM noted bilaterally. Left lower extremity nontender to palpation, no swelling noted. Full ROM noted left hip, knee and left ankle. RIGHT Lower extremity-Full ROM noted hip and knee. Nontender to palpation. RIGHT ANKLE swelling noted, no redness. Tender to palpation, limited ROM. No obvious dislocation of foot/ankle. Ottawa Ankle Rules noted pain in the malleolar area lateral right ankle, with tenderness noted distal fibula upon palpation. Able to bear weight rt foot but with pain 8/10. Able to move toes. Pain increases upon dorsiflexion of foot. Drawer test Right foot shows increased instability indicating possible tendon involvement. Musculoskeletal: Equal strength BUE, radial pulses noted. Rt foot weaker than left upon dorsiflexion. Bilateral pedal pulses noted, capillary refill <3sec. Neuro: Cranial nerves II to XII grossly intact, no neurologic deficits noted, grip strength equal. Diagnostic results: XRay right ankle: Boehler’s angle noted to be 20degrees, no other obvious fracture noted. Boehler’s angle has a significant correlation with calcaneal fractures if found to be less than 20 degrees (University of Washington, 2020). A. Differential Diagnoses 1. Right ankle pain as evidenced by pain 8/10 and difficulty bearing weight (Ball, et. all., 2019). 2. Possible calcaneal fracture as evidenced by Boehler’s angle 20 degrees, difficulty bearing weight (University of Washington website, 2020). 3. Grade II right ankle sprain as evidenced by pain and instability with drawer test and dorsiflexion (Chung & Chung, 2019). 4. Cannot rule out possible torn right peroneus longus and brevis as evidenced by pain on dorsiflexion of right foot (LeBlond, et. al., 2015) P. 1. Jones splint and crutches for instability and assistance walking. 2. MRI right ankle to assess tendon involvement. 3. Will discuss with patient appropriate pain medicine, rx for 3 days as per State and FDA requirements. 4. Return to clinic in 1-2 weeks for results review and recheck of ankle. References Anatomy of the Foot: Arthritis Foundation. (n.d.). Retrieved from https://www.arthritis.org/health-wellness/about-arthritis/where-it-hurts/anatomy-of-the-foot Ball, J., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidels guide to physical examination: an interprofessional approach. St. Louis, MO: Elsevier. Bohler angle. (2020). Retrieved April 15, 2020, from https://faculty.washington.edu/jeff8rob/trauma-radiology-reference-resource/11-lower-extremity/bohler-angle/ ChungDr, A., Chung, A., & Philadelphia College of Osteopathic Medicine. (2019, July 29). Health Pages. Retrieved April 15, 2020, from https://www.healthpages.org/anatomy-function/anatomy-foot-ankle/ ChungDr, A., Chung, A., & Philadelphia College of Osteopathic Medicine. (2019, August 22). Health Pages. Retrieved from https://www.healthpages.org/health-a-z/ankle-sprain/ LeBlond, R. F., Suneja, M., Szot, J. F., & Brown, D. D. (2015). DeGowin’s Diagnostic Examination (10th ed.). New York, NY: McGraw-Hill Education. please response to this post

ANSWER. PAPER DETAILS
Academic Level	Masters
Subject Area	Nursing
Paper TypeÂ	Coursework
Number of Pages	1 Page(s)/275 words
Sources	3
Format	APA
Spacing	Double Spacing

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